Human rights are
important for all strata, classes and races of the society. But it
assumes special significance for mentally ill clients, who because of
their vulnerability due to illness, often fail to prevent violation of
their rights. Often the violation of rights occurs right from the
admission in mental hospital, until discharge from the hospital.
Frequently, the same violations of the rights of the mentally ills also
occur in prisons, shelter homes and streets. Often the very efforts to
protect the rights of mentally ill clients lead to violation of the
rights. The group, which is marginalized, discriminated and stigmatized
by the society, can only be helped by the society. The society can help
the mentally ill clients by enacting laws favorable for them, by
providing proper facilities for community based treatment, protecting
their rights at mental hospitals and by rehabilitating them in society
after discharge from the
hospital.

The human rights of mentally ill clients are very
important because, unlike other aggrieved groups, they are unaware of
their rights most of the time, hence do not stand up and fight for
them. People suffering from mental illness are among the most
disadvantaged groups in society. Further, they suffer severe personal
distress and they are stigmatized, discriminated against, marginalized
and often left vulnerable. [1] The protection of rights becomes more
pertinent in a mental hospital because the moment a client enters into
the hospital, he cannot venture outside the hospital premise on his own
volition, unless a doctor certifies that he is fit to do so. Once in
the institute his moments, if not restricted are not as free as they
are in the outside world and his daily activities are likely to be
scheduled according to the hospital rules. Everyone has the basic human
rights, including those who are mentally ill. Everyone has the right to
a standard of living adequate for the health and well-being of himself
and of his family, including food, clothing, and housing and medical
care and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old age or
other lack of livelihood in circumstances beyond his control. [2]
People with mental illness commonly experience violations of rights,
including their economic and social rights. One of the reason for ill
treatment of the clients may be due to decreased or absent contribution
in the economic field by mentally ill clients unlike the clients having
medical illness. [3] The Mental Health Act (MHA), 1987, came into force
in 1993. It repealed the much-criticized the Indian Lunacy Act, 1912.
The aim of the act was to protect the human rights of mentally ill
people, but many people involved in the field feel that the law has too
many lacunae and needs urgent attention. The findings of the recent
study concluded that the human rights of people with mental illness
were not protected influencing their reintegration into the
community.[4] World Health Organization (WHO) states that we are
“facing a global human rights emergency in mental health” as many
countries lack the basic legal framework to protect those with a
disability.[5]

Human rights at Mental Hospitals: As
nations have flags as their symbols of patriotism, so humanity has
unreformed mental hospitals as symbols of human right violations. When
one undertakes a task to improvise facilities at the mental hospital,
one should not lose sight of the fact that one is improvising the
facilities of a prison like structure which, even if turned into gold
would still retain its original character of a prison. The condition in
mental hospitals is often grim in absence of cleanliness, hygiene,
entertainment facilities, restricted freedom to move at will and poor
staff to client ratio. Often the hospital lacks psychiatrists, good
paramedic support, psychiatric social workers, clinical psychologists
or occupational therapists on board to fulfill the requisite angles of
the treatment being meted out. [6][7] The study conducted in the
tertiary care institute in India concluded that the human rights of
people with mental illness were not protected that influenced their
reintegration into the community. [8]

Many a time, even when
clients get cured his or her guardians don’t turn up and such clients
are forced to languish in mental hospitals, despite being fully fit to
be discharged. Twenty percent of all clients in mental hospitals in
Kolkata are fully fit to resume their normal life, but because of lack
of rehabilitation facilities and post-care treatment, these people are
condemned to languish in the hospitals that are no more than jails. [9]
The other consequence of this development is overcrowding of the
hospitals because of which deserving clients do not get proper
treatment at the institute. [10] Many a time hospital staff witnesses a
condition in which a cured client becomes aggressive because he or she
cannot be sent home due to various reasons and the client may develop
suicidal wishes or a wish to escape from the hospital.

In an
ideal Utopian world, facilities like adequate and hygienic space,
air-conditioning, heaters, privacy, means of entertainment, gainful
employment, etc., should be available to inmates of custodial homes
like mental hospitals, jails, juvenile homes, etc. The same facilities
should be available to inmates of shelter homes, halfway homes, quarter
way homes, beggar's home, daycare shelters and rehabilitation centers.
However, the truth is the significant number of the population of the
world lacks even basic needs like food and shelter. Due to recession
and other factors, government over the world is pulling out their hands
from social spending. New York a city of developed country famous for
glitz, glamour and billionaires is having a dubious record of 60,000
people, who are homeless. [11] The governments’ world over with poor
resources is in dilemma to provide the home to poor people first or to
mentally ill first. Such a situation necessitates judicious use of
available resources as well as a sustained effort with government for
allocation of required resources.

Violation of Human Rights at Mental Hospitals:There
are certain sets of problems, which one is more likely to witness in
mental hospitals than in any other hospitals. The reasons are, the
other hospitals are under the direct vigil of the public, which makes
hospital staff and authorities alert to the clients’ problems. The
second is, in other hospitals, client themselves are alert for their
rights, which makes staff and administration sensitive to clients’
requirements, while in case of mentally ill clients they are completely
at the mercy of the hospital staff.[12] Perhaps, the first violation of
human rights occurs when a client is admitted in unreformed mental
hospital. Human right is violated when a cured mentally ill and
well-fed client yearns for freedom in a mental hospital. The scene
frequently repeated in the mental hospital is client cured, half cured
or uncured, yearns for discharge from the hospital and his relatives or
caretakers unwilling to take him back at home. The psychiatrist working
in the institute becomes an unwilling judge in the battle of wills. The
psychiatrist again becomes unwilling judge when he has to choose
whether the interest of the client is paramount or interest of his
relative. He becomes unwilling judge when he has to choose between the
safety of his psychiatric practice and interest of a paranoid and
potentially litigious client. Similarly, human right is violated when a
wandering mentally ill yearns for shelter and food on the streets.
Human right is violated, when a cured client cannot be sent back home
because either his relatives are unwilling to take him back or he
doesn't have a home where he can be sent back. Human right is violated,
when the valid anger or aggression of a cured client who wants
discharge from the hospital, is controlled with involuntary admission
of drugs. Human right is violated, when a mental hospital is
established without rehabilitation centers in its vicinity. Human right
is violated, when past history of mental illness is invoked to;
intimate the client, control him or coerce his normal behavior. Human
right is violated, when admission in a mental hospital is used as a
pretext to control the property of the client. Human right is violated
when a client lives in constant fear that he would be admitted in the
hospital for the vested interest of his relatives, e.g. for a purpose
of divorce or to usurp his property. Human right is violated when a
client is made to work against his will in a mental hospital for fear
of being punished or for a petty reward like cigarette or tobacco.
Human right is violated when the client doesn’t receive evidence based
treatment. Human right is violated when clients are used for clinical
trials without their consent. Human right is violated when the
administrative authorities of mental hospital are not vested with
adequate power and protection against the delinquent staff working at
the institute. Human right is violated when the adequate and hygienic
space, privacy, means of entertainment, gainful employment, etc., are
not available to inmates of mental hospitals. Human right is violated
when a client feels more comfortable in hospital than at home due to
economic circumstances. Human right is violated when a prisoner
develops mental illness in a prison. Human right is violated when a
person is imprisoned, even when he breaks a law in a state of mental
illness. Human rights are violated of both, a doctor and a client, when
the former cannot give adequate time to the client due to work overload
and the later cannot get proper attention for the same reason. Human
rights are violated when mental health care is not geographically
accessible according to WHO(World Health Organization) guidelines.[13]
Human right is violated when an evolving science of psychiatry is used
to label a person with revolutionary thoughts as lunatic to force him
into conformity. Human right is violated; when a doctor short of time
uses a nascent science of psychiatry, in haste, to label the client
with psychiatric illness, the criteria of which changes from time to
time.

Human Rights and Restraint of mentally ill:Physical
restraints of people with mental illness have a long and infamous
history that starts with a period of ancient Greece, where mentally
ills were chained, to the dark period of ‘Bedlam hospital’, wherein
shackled clients were put on display for the price of a penny. [14] In
Indonesia, there is a practice known aspasung, in which people with
mental illness are chained, tied, confined in small rooms or sheds, or
have their legs in wooden stocks. [15] The process of freeing the
people from physical restraints was started by Philippe Pinel and
Jean-Baptiste Pussin who are credited with releasing the mentally ill
from the chains at the Bicêtre and the Salpêtrière hospitals in Paris
at the end of the 18th century. [16] The same process of releasing
clients from the restraint continues today with a goal of releasing
clients not only from the physical restraints but also from the
unnecessary chemical restraints.

In ideal conditions of a
Utopian world, no mentally ill human being should be physically
restrained or kept in isolation. Some would say the ideal thing would
be the use of chemical restraints not physical restraints during
hospitalization. But whether we restrain client's hands by mechanical
restraints or client's brain cells by unnecessary chemical restraints
(neuroleptics means grasping the neurons), it is the same thing. The
latter thing may be aesthetically more pleasant, but is more damaging
to the human soul and mind than the former thing. The unnecessary
chemical restraints may not show outer scars on the body, but it
definitely causes neuronal scars, which manifest eventually as tardive
dyskinesia and other adverse effects.

Desire for freedom: A Core of Human Rights: The
‘desire for freedom’, is a linchpin of human rights, which forms core
not only of the human beings but also of the animal beings. The ancient
Indian civilization has advocated four goals for human life namely
dharma (righteous conducts), artha (material and social needs), kama
(sense pleasures) and moksha (freedom). The Supreme Court of India,
while delivering one landmark verdict gave paramount importance to
personal liberty and said that no one will ever barter his liberties
for all the teas of China, all the pearls of the seas and all the stars
of the sky.[17] The freedom also includes the freedom from a
stigmatizing diagnosis. Often, the process of diagnosing the clients
itself is a stigmatizing process, producing mental scars which are
difficult to be hidden, even if one applies a makeup of ‘Destigmatizing
Campaign’. A diagnosis of psychiatric illness hinges on a base of
reality testing. However, according to Albert Einstein, reality is an
illusion albeit a very persistent one. [18] So to diagnose the mental
illness solely on a base of reality testing becomes a tad unscientific,
unless it is done with humility that the diagnosis one putting is a
temporary construct about the condition one know very little. Instead
of diagnosing the clients with stigmatizing diagnosis like
schizophrenia that denotes that unlike normal people, only the people
suffering from mental illness are in two minds; one can use Japanese
terminology like ‘Integration Disorder’, which may better reflect the
true nature of an underlying disorder. [19][20]

It is
not difficult to imagine the plight of wandering homeless mentally ill
client, who has been admitted in mental hospital and cured
subsequently. The client cannot be sent home as he or she is without a
home. The condition becomes poignant when the client does not want to
go in shelter home or rehabilitation home. Moreover, it is not legally
or morally appropriate for hospital authorities to release the client
on the road from a custodial care hospital. Similarly, it is not
appropriate to see the cured client languishing and thus suffering in
mental hospital. The paternalistic role of welfare state directs to
take care of wandering mentally ill person and put him or her into some
institution, but what if some person is happier wandering like a fakir
or mendicant than being confined to a mental hospital or other
custodial care institution. What if some person writes in his advance
directive that should he develop mental illness in the future, he
should be left alone as wandering ill and ill-fed rather than be
confined to some custodial institution and be fed well. In such a
situation should state take away the freedom it provided to the person
on the bases of which he chose freedom or should it renege on its
promise to provide freedom.

Human rights: More emphasis leads to more violation: Everything
in excesses is bad and it may be true with the advocacy of human rights
as well. Ideally, there should be no overcrowding in mental hospitals,
but if rules be followed strictly without adequate numbers of mental
hospitals in the country, then it may lead to overcrowding of mentally
ill clients on the streets and in prisons. [21][22] When the
institutions that cater to the needs of mentally ill clients, are under
excessive legal or public scrutiny, they become defensive in response
to challenges thrown by the mental health field. They may order the
unnecessary investigations for clients to avoid blame in case of any
eventuality. This may not only increase the overall cost of treatment,
but also cause mental harassment to clients and their relatives and the
indirect violation of human
rights.

Excessive scrutiny may avert an incident of a major human right
violation, but the resultant sum-total of minor human rights violation
that would ensue because of such scrutiny would far exceed the total
number of gross human right violations. Ideally the mentally ill
clients should be investigated thoroughly (including CT Scans and MRI
Scans) before he receives the diagnosis of mental illness. However,
this would amount to a colossal waste of already meager resources. The
18th century English philosopher formulated what came to be known as
'felicific calculus': a means by which to gauge how to ensure the
greatest amount of happiness for the greatest number. Therefore,
according to this principle, there is little harm in skipping certain
procedures, if resources are scarce and the benefits that would accrue
from such money saving steps would far outweigh the possible harms.
However, such omission should be legally protected as it is done in New
Zealand. [23]

The excessive scrutiny may lead mental health
professional to defensive practice. The defensive practice can be
defined as “ordering of treatments, tests and procedures for the
purpose of protecting the doctor from criticism rather than diagnosing
or treating the client”. [24] Defensive medicine takes place when
doctors prescribe unnecessary tests, procedures or specialist visits
(positive defensive medicine), or avoid high risk clients or procedures
(negative defensive medicine). [25] These types of practice occur
whenever a practitioner gives a higher priority to self-protection from
blame than to the best interests of the client. A large number of legal
initiatives taken by clients have induced many doctors to adopt a
defensive “strategy” to avoid jeopardizing their careers. Controversies
in mental health, and occasional tragedies, are often the subject of
close media attention and reporting which may be inflammatory. [23] A
mail survey of physicians in Pennsylvania concluded that nearly all
(93%) reported practicing defensive medicine. [26] The study
conducted in England concluded that almost three quarters of the
psychiatrists who responded had practiced defensively within the last
month of the survey.[27] Therefore, “No blame” and “learning
culture”, is essential for the delivery of quality health care
services.[28]

The same trend of defensive practice also
seeps in the management of custodial setup. Ideally, one should give
more freedom to clients by building the setup of mental hospital in
such a way that it doesn’t appear like a prison or a jail. However,
from such setup if client escapes, then it leads to a kind of inquiry.
The other option to employ more staff who can keep watch over clients
in such setups often violates the privacy of the client and escalates
the cost of maintenance of the hospital. Therefore, because of this
fear, hospital staff restricts the movement of the client and thus
violates human rights.

In many mental hospitals in India, the
death of the inmate is investigated by police and death audit
committee. Similarly, in western countries, critical incidents, such as
suicides, homicides, and deaths while detained under the Mental Health
Act are investigated by both trust and coroner’s inquest. The
investigations may be followed by negligence claims from the relatives.
These investigations may provide the source of incentives to act
defensively. When the professionals feel that their each and every
action they take or action they avoid are under scrutiny and are liable
to be dissected by a group of people, they may choose a field in which
a risk of litigation is less. The net result would be a shortfall of
professionals in such institutes or if the professionals are available
there are chances that they are not the best in their field. No wonder
Bombay high court recently opined that the conditions of mental
hospitals were deplorable and no psychologists or psychiatrists were
available at any of the hospitals and none of the hospital had a
rehabilitation program. [29] Still, surveillance and the inquiry of
untoward incidents are necessary, but it should be in such a way that
it doesn’t cause violation of human rights, intentionally or
unintentionally, it intends to protect.

Role of Mental Hospital in Protection of Human Rights: Until
the better option of mental hospitals is found, mental hospitals still
have some role to play in the treatment of mentally ill clients.
Clients in some state mental hospitals were poorly treated, mistreated,
or maltreated in the past does not mandate that a new public mental
hospital system would do so. Opponents of reinvigorating the public
mental hospital system argue for community programs. Community programs
are important, but serve a different purpose in the continuum of care
for the severely mentally ill. [30]

If we don’t provide a safe
institutional environment for aggressive and violent clients, more
psychiatric hospitals will close leading to those clients being
secluded and restraint in the non-therapeutic environments of prisons
and jails. [31] Therefore, this approach of treating the client solely
in community, leads to undesirable consequences like: utter neglect of
the client by his relatives; frequent contact with criminal justice
system and more people in beggar homes, shelters, streets and jails
instead of mental hospitals.[32] Another benefit of a psychiatric
institution is that it can provide centralized, coordinated care for an
individual with severe mental illness, when the available psychiatric
services in the community are fragmented and are poorly coordinated.[33]

individual,
regardless of whether or not they have been assigned a psychiatric
diagnosis, is expected to undergo some experience that limits the harm
they can generate. [34] If we consider parents’ insistence on sending a
reluctant child to school as human right violation, then the whole
world would soon revert to a stone age where there would be no human
rights whatsoever. When the normal people exhibit the violent behavior,
they should be counseled and may be needed to be sent to the jail; same
way violent behavior in mentally ill client needs to be controlled
first by psychotherapy and antipsychotic drugs and lastly by
temporarily confining him or her to a mental hospital.[35]

Therefore,
violent and uncontrollable behaviors need to be controlled by temporary
hospitalization. However, while admitting the client in the mental
hospital, one should be aware that it is a temporary measure to treat
the client, until he is transferred to halfway home, quarter way home,
and shelter home or rehabilitated in society. It is always desirable
that all long-term admissions of more than six months should be
evaluated by a team comprising, a member of the judiciary, an expert of
the social science department and a psychiatrist, with an aim of
transferring the clients from inside the hospital. The other important
issue is human rights of mentally ill prisoners. The recent study in
India showed that 33% of the convicted prisoners were suffering from
psychiatric illness. [36] If after giving sufficient treatment a
mentally ill prisoner doesn’t improve, he may be sent to another
institution for treatment and if three or more institutions after
giving sufficient treatment, certify that client is not likely to
improve then the client may be given a bail to prevent further
deterioration of his condition and to minimize overcrowding of the
jails and hospitals. The reason for sending a mentally ill prisoner in
three or more institutes is to make sure that prisoner gets sufficient
treatment by different psychiatrist that would prevent him from
subverting the system by faking symptoms of mental illness.
Alternatively, if after giving sufficient treatment, if mentally ill
prisoner doesn’t improve and at the same time if he is not fit to be
discharged from the hospital, then he may be converted into a non
criminal inmate, which would increase his freedom at the institute and
consequently increases the chances of recovery. The treatment in a
mental hospital would become useless, if mentally ill prisoner is going
to develop symptoms of institutionalization instead of being cured of
his illness.

Steps to Protect Human Rights: The
first step to protect the human rights of the mentally ill client is
not to admit him in the institution unless absolutely necessary;
instead he should be provided with community based treatment and
rehabilitation services. If at all, admission is necessary, he should
be ideally admitted in an open ward with relatives for a short duration
of time. Admission with relatives would prevent anxiety in a client who
is admitted in an unfamiliar place. He should be provided an evidence
based treatment during admission. In addition, as soon as he is
manageable he should be handed over to his relatives. However, in
absence of relatives he should be rehabilitated in halfway homes or a
quarter way homes. To admit the client in unreformed institute and then
protecting his human rights are like inflicting a wound on a person and
then treating it. So the judicious use of available resources would be
helpful in protecting the right of mentally ill clients.

While
dealing with agitated client, the first thing should be employed is
verbal de-escalation with or without oral medication. Verbal
de-escalation techniques, undertaken with genuine commitment have the
potential to decrease agitation and reduce the potential for associated
violence, more often than previously thought possible. [37] As
far as possible, physical restraints, seclusion and chemical restraints
should be used as a last resort while following the guidelines of the
institution the client is admitted. While admitting the client, one
should be aware that it is a stop-gate arrangement, until the client is
rehabilitated in society or in some rehabilitation home, which permits
more freedom to the client.

Conclusion: We have
progressed a great deal in protection of human rights of mentally ill;
from the past when they were physically restrained brazenly to a recent
period, when even the chemical restraints are used cautiously. We have
to walk on tightrope to protect human rights because, many a time our
very effort to protect human rights by increasing vigilance leads to
violation of human rights. Still, more needs to be done in the field
that would require multiple strategies that start from judicious use of
antipsychotics to increase in awareness in clients and their
caregivers. The changes in the nomenclature of disease that stigmatizes
the clients may also help in this direction. The Human Right
Commissions, civil society organizations, and health professionals and
health service provision agencies all have important roles to play in
the protection of human rights. [38] Psychiatrists can promote human
rights through scrutinizing the admissions in mental hospitals,
providing evidence-based medicine, ensuring a short stay of clients in
a mental hospital, and actively participating in the rehabilitation of
clients in society.

References

1.
Johnstone MJ. Stigma, social justice and rights of mentally ill:
challenging the status quo. Australian and New Zealand Journal of
Mental Health Nursing 2001; 10:200–209.

2.
Universal Declaration of Human Rights, adopted and proclaimed by the
United Nations General Assembly by resolution 217A (III) on 10 December
1948. Available from: http://www.un.org/Overview/rights.html. [Last
accessed on 2015, Aug 15].

11.
Homeless reaches record 60,000 in New York. Times of India. Feb 4,
2015. Available from:
http://timesofindia.indiatimes.com/world/us/Homeless-reaches-record-60000-in-New-York/articleshow/46115138.cms.[
Last assessed on 2015, Aug 26]

30.
Kramer DA. If It Were Physical Pain, It Would Be Called Torture: A
Story of Two Young Men. Psychiatric Times. March 25, 2015. Available
from:
http://www.psychiatrictimes.com/cultural-psychiatry/if-it-were-physical-pain-it-would-be-called-torture-story-two-young-men?GUID=D7BE0FA8-937A-4FEF-8651-8E9F45FC1CB1&rememberme=1&ts=04042015.
[ Last Accessed on 2015, May 6]

31. Moosa MYH,
Jeenah FY. The use of restraints in psychiatric clients. South African
Journal of Psychiatry 2009; 15(3).